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Continue on the back if necessary What could have been done to prevent this injury/near miss What parts of your body were injured If a near miss how could you have been hurt Did you see a doctor about this injury/illness If yes whom did you see Doctor s phone number Date Has this part of your body been injured before If yes when Time Your signature Supervisor s Accident Investigation Form Name of Injured Person Date of Birth Telephone Number Address City Circle one Male State Zip Female What...
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Employee Accident Report Form
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